For decades, the widening gap between the upper and lower numbers in a blood pressure reading—known as pulse pressure—has been attributed to falling estrogen levels during menopause. However, a new analysis from the Framingham Heart Study published in Hypertension reveals that this change begins about two decades before women enter menopause, suggesting that factors other than menopause timing are at play.
The study, which followed 6,760 women over 14 years, found that pulse pressure reached its lowest point and began to rise in women in their late 30s, compared to late 40s in men. Whether menopause occurred early, late, or at a typical age had no influence on when this transition happened. “To our huge surprise, our results suggest that factors other than the timing of the final menstrual period were likely involved in the accelerated increase in pulse pressure in women after midlife,” said senior author Gary F. Mitchell, M.D.
Aortic stiffness is the underlying mechanism. The aorta, the body’s largest blood vessel, stiffens with age, and women start life with fewer elastic fibers in the aorta, making them more susceptible to this stiffening. As the aorta becomes less flexible, pulse pressure widens, forcing the heart to work harder and potentially damaging small vessels in the brain and kidneys. Wide pulse pressure is an independent risk factor for cardiovascular disease, dementia, and kidney disease, and it may make high blood pressure less responsive to standard medications.
“Healthcare professionals should definitely consider pulse pressure in middle-aged and older patients – especially women – with high blood pressure,” Mitchell said. He noted that women are often told that a “borderline” blood pressure reading, such as 130 mm Hg systolic, can simply be monitored. “However, women and their doctors should sound the alarm if pulse pressure is higher than 60 mm Hg [such as 130/70 mm Hg] and track it over time to see if pulse pressure is rising.”
Samar R. El Khoudary, Ph.D., M.P.H., FAHA, who chaired the writing group for a 2020 American Heart Association scientific statement on the menopause transition, emphasized that vascular aging may begin years before menopause. “We shouldn’t wait until menopause to start thinking about cardiovascular health. By the time a woman reaches her final menstrual period, vascular changes may already have been underway for years. Midlife is an opportunity to identify cardiovascular risk early and intervene before disease develops.”
The findings have significant implications for clinical practice. Pulse pressure is currently not included in blood pressure management guidelines, but the study authors argue it should be. Greater attention to pulse pressure could help guide tailored treatment approaches, as high blood pressure with a wide pulse pressure is less likely to respond to usual therapies. The study also underscores the need for early cardiovascular risk assessment in women, well before menopause.
Limitations of the observational study include the inability to prove cause and effect and reliance on self-reported menopause age. Most participants were of white European descent, so results may not apply to other racial or ethnic groups. The Framingham Heart Study has been supported by the National Heart, Lung, and Blood Institute and led by Boston University since 1971.
